The doctor dictates an excision of soft tissue mass. The pathology report comes back as being endometriosis. When the Dr's office scheduled the case, they sent it over as CPT 22900 which is excision of a tumor of the abdominal wall which I do not agree with. However, I can't seem to find a CPT that would be the best fit. Any input would be greatly appreciated.
PREOPERATIVE DIAGNOSIS: Soft tissue mass, anterior abdominal wall.
POSTOPERATIVE DIAGNOSIS: Vascularized scar tissue at C-section scar, rule out endometriosis.
PROCEDURE: Excision of soft tissue mass.
FINDINGS: Subcutaneous scar tissue adherent to the anterior fascia in the midline and to the right side measuring 3 cm x 2 cm. This appeared to be more vascular than the routine scar tissue that was seen in this area. No ventral hernia was noted.
INDICATION: This is a 36-year-old female presenting with painful tender swelling in the midline 18 months after cesarian section. She has no urinary symptoms and no discharge from the area.
PROCEDURE IN DETAIL: After adequate induction, lower abdomen was prepped and draped. Skin and subcutaneous tissues through the scar of previous C-section were infiltrated with the local anesthetic, consistent ing of 0.25% Marcaine and lidocaine. Then, 3-4 cm transverse incisions were made. Subcutaneous tissue was divided. The scar tissue was separated from the subcutaneous tissue and the deeper fascia in all direction and was completely removed. Feeding vessels were cauterized. A small defect in the fascia was approximated with continuous 1-0 Vicryl suture. Subcutaneous tissue was approximated with 3-0 Vicryl and skin with 4-0 subcuticular Vicryl sutures. Dry occlusive dressings were placed. The wound was irrigated with saline solution prior to closure.
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